Endo 21

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A 45-year-old woman presents to clinic with a 4-month history of headaches

and changes in her vision. She has been previously healthy and has not been
on any medications. On examination, she is found to have a small field
defect in both eyes. The diagnosis of a pituitary microadenoma is
entertained. Which of the following tests would be the most sensitive in
diagnosis of such an entity?
A. Computerized tomography (CT) scan

B. Insulin-tolerance test
C. Magnetic resonance imaging (MRI)
D. Serum prolactin measurement
E. Visual field examination
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A 18-year-old woman is brought to the clinic by her parents, who report that
she has been increasingly weak and fatigued for the past 6 months. She has
no prior medical history and denies any medication use. On physical
examination, she has a blood pressure of 85/60 mm Hg and is tachycardic
with a pulse of 110/min. Laboratory studies are notable for a normal sodium,
potassium of 2.2 mEq/L, and a plasma bicarbonate of 44 mEq/L. Which of
the following is the most likely cause of her hypokalemic alkalosis?
A. Chronic diarrhea
B. Cushing syndrome
C. Licorice ingestion
D. Primary aldosteronism
E. Surreptitious vomiting
A 55-year-old man consults a physician because of episodic weakness and

paresthesias. On one occasion, he experienced transient paralysis. The
patient has also been experiencing polyuria and polydipsia. Vital signs
demonstrate a blood pressure of 140/100 mm Hg with normal temperature,
pulse, and respirations. The remainder of the physical examination is
unremarkable and specifically shows no significant abnormal neurologic
findings and no peripheral edema. Routine screening chemistry studies are
remarkable only for a serum potassium of 2.1 mEq/L. CT scan demonstrates
a small adrenal mass. Which of the following is the most appropriate
pharmacotherapy to treat this patient's hypertension?
A. Captopril
B. Furosemide
C. Hydrochlorothiazide
D. Propanolol
E. Spironolactone
A 64-year-old woman comes to the emergency department because of severe

wrist pain after a fall. She says that she fell on an outstretched hand 2 days
ago, and has been experiencing severe pain ever since. She has had 3
episodes of nephrolithiasis, chronic muscle weakness, and vague abdominal
complaints over the past few months. Physical examination is normal. A x-
ray film of her wrist shows a fracture of the distal radius and osteopenia.
Laboratory studies show:
Sodium.............139 mEq/L
Chloride ...........94 mEq/L
Potassium........4.5 mEq/L
Bicarbonate.....23 mEq/L
Calcium ..........13 mEq/L
Uric acid.........5 mg/dL
A splint is placed on her wrist and a follow-up visit is scheduled. Which of

the following is the most likely explanation for these findings?
A. Decreased excretion of uric acid

B. Development of thyroid-stimulating hormone receptor antibodies
C. Elevation of circulating aldosterone
D. Elevation of circulating cortisol
E. Elevation of circulating parathyroid hormone
One month following delivery of her baby, a new mother complains to her
physician of feeling very tired and cold all of the time, even when she gets
adequate sleep. Physical examination is notable for marginal thyroid
enlargement without tenderness. Thyroid studies show a total T4 of 3.5 •g/
dL, with third-generation studies showing a thyroid-stimulating hormone
(TSH) of 7.5 •U/mL. Which of the following is the most likely diagnosis?
A. Euthyroid sick syndrome

B. Graves disease
C. Iodine deficiency
D. Silent lymphocytic thyroiditis
E. Subacute thyroiditis
A 48-year-old man comes to the physician because of the recent onset of

obesity and easy bruisability. His blood pressure is 165/95 mm Hg. Dermal
striae are found on physical examination. A dipstick examination of urine
reveals glycosuria. Which of the following is the most appropriate next step
in diagnosis?
A. Baseline plasma ACTH measurement

B. CT scans of the chest and abdomen
C. Dexamethasone suppression test
D. Measurement of midnight serum cortisol level
E. Measurement of 24-hour urine cortisol and
creatinine
F. MRI scans of the head
A 23-year-old type 1 diabetic is brought to the emergency department after

being found in a coma. The scent of acetone is present on the patient's breath.
Urinary catheterization with subsequent dipstick analysis demonstrates
marked positivity for glucose and ketones. Stat blood chemistries would
most likely show which of the following values for the anion gap?
A. 6 mEq/L
B. 11 mEq/L
C. 13 mEq/L
D. 15 mEq/L
E. 20 mEq/L
A 60-year-old woman complains of a 1-year history of bone pains, anorexia,

weight loss, and constipation. Serum calcium is elevated and she is
diagnosed with primary hyperparathyroidism. She is treated surgically, with
removal of her parathyroid adenoma. She then has a long period of
hypocalcemia and requires continuous treatment with vitamin D and
calcium. Subsequently, after 6 months she becomes normocalcemic and does
not need therapy. Which of the following conditions best explains these
events?
A. Her remaining 3 parathyroid glands were destroyed

B. She has unrecognized pseudohypoparathyroidism
C. She had severe bone disease
D. She has pancreatitis from hyperparathyroidism
E. The wrong parathyroid gland was removed
One year following a difficult birth, which was accompanied by considerable

blood loss, a 30-year-old woman comes to the physician complaining of
profound fatigue, loss of appetite, cold intolerance, and constipation. She
denies feelings of depression, but she feels constantly apathetic and tired and
has no sexual drive. Her menses have not resumed after delivery. Her blood
pressure is 100/65 mm Hg. Examination reveals dry and pale skin, with thin
and brittle hair. Which of the following is the most likely diagnosis?
A. Postpartum depression
B. Primary adrenal insufficiency
C. Primary hypothyroidism
D. Sheehan syndrome
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A 45-year-old man presents to a physician with complaints of weakness,

fatigue, and feeling near fainting when he stands up quickly. Screening
chemistry studies demonstrate sodium, 128 mEq/L; potassium, 5.2 mEq/L;
bicarbonate, 17 mEq/L; and urea nitrogen, 45 mg/dL. The physician is
considering Addison disease in his differential diagnosis. Which of the
following features on physical examination would be most suggestive of this
diagnosis?
A. Black freckles on the shoulders

B. Large, furrowed tongue
C. Many spider angiomas
D. Protruding eyeballs
E. Small glistening bumps on the lips
A 45-year-old woman is taken to an emergency department after an all day

car trip, during which she did not have adequate access to fluids. She had
required many bathroom stops, including three times when she had urinated
behind a tree because no bathroom was immediately available. In the
emergency department, she is found to have severe postural hypotension.
Urine dipstick is negative for glucose. She continues to produce large
volumes of urine, and urine osmolarity is low. On questioning, she has not
noted any unusual drinking pattern, but her husband states that she "usually
goes through four six-packs of diet soft drink" every day. The patient's
condition improves with IV fluid replacement. Vasopressin injection
increases her urine osmolarity by more than 50%. Which of the following is
the most likely diagnosis?
A. Central diabetes insipidus

B. Compulsive water drinking
C. Diabetes mellitus type I
D. Diabetes mellitus type II
E. Nephrogenic diabetes insipidus
A 53-year-old man comes to the physician because of progressive weakness

and weight loss over the past 2 months. He says that he also began noticing
areas of his skin getting darker even though it is winter and he is never in the
sun. He takes no medications and has no other medical conditions. Physical
examination shows no abnormalities except for orthostatic hypotension and
hyperpigmentation of his skin. Laboratory studies show:
Sodium........................130 mEq/L
Chloride ......................95 mEq/L
Potassium...................6.5 mEq/L
Bicarbonate................20 mEq/L
Leukocyte count..............5000/mm3
Segmented neutrophils......40%
Band forms ......................4%
Lymphocytes...................40%
Monocytes .....................6%
Eosinophils......................9.5%
Basophils........................0.5%
Which of the following is the most likely diagnosis?
A. Addison's disease
B. Conn's syndrome
C. Cushing's disease
D. Cushing's syndrome
E. Syndrome of inappropriate antidiuretic hormone secretion
A 45-year-old alcoholic man with cirrhosis is transferred to the intensive care

unit after developing esophageal varices complicated by shock. A screening
battery of tests is ordered, revealing a total thyroxine (T4) of 3.8 mg/dL.
Physical examination of the thyroid gland is unremarkable. Follow-up
studies showed a total triiodothyronine (T3) of 30 ng/dL and TSH (third-
generation test) of 0.7 mIU/mL. Which of the following is the most likely
diagnosis in this patient?
A. Euthyroid sick syndrome

B. Graves disease
C. Hashimoto disease
D. Medullary carcinoma of the thyroid
E. Silent lymphocytic thyroiditis
A 52-year-old woman is seen by in clinic for advice on osteoporosis. She has

been a patient there for a number of years. She has a past medical history
significant for hypertension and diet-controlled diabetes mellitus. She
smokes 1 pack of cigarettes per day. She was documented by previous LH
and FSH levels to be in menopause within the last year. She is concerned
about "breaking her hip when I'm old" and she is seeking advice on
osteoporosis prevention. She should be told that independent of side effects,
the best therapy currently available for prevention is which of the following?
A. Bisphosphonates
B. Calcitonin
C. Calcium and vitamin D
D. Conjugated estrogens
E. Sodium fluoride
A 18-year-old man presents for a health maintenance examination. He has a

family history of Tangier disease, and a number of adults in his family have
either hepatosplenomegaly, recurrent polyneuropathy, or both. Which of the
following would be the strongest finding on physical examination to suggest
the presence of this disease?
A. Angiokeratomas
B. Grey-brown pigmentation of the forehead, hands, and pre-tibial
region
C. Irregular black deposits of clumped pigment in the peripheral retina
D. Orange-yellow tonsillar hyperplasia
E. Pingueculae
A 42-year-old man presents with a 1-day history of increasing nausea,

vomiting, and lethargy. He has an extensive smoking history and was
recently diagnosed with lung cancer. He is not taking any medications and
has not yet initiated chemotherapy. On physical examination, he is afebrile
and somnolent. His lungs are clear to auscultation, and his heart is regular in
rate and rhythm. His skin shows eroding calcium deposits. Laboratory results
indicate a serum calcium level of 13.4 mg/dL. Which of the following is the
most appropriate initial step in management?
A. Calcitonin
B. Etidronate
C. Hydrochlorothiazide
D. IV saline
E. Prednisone
A 25-year-old woman comes to the physician 4 weeks after an uneventful

delivery because of increasing irritability, anxiety, and heat intolerance. Her
temperature is 37.2 C (99 F), blood pressure is 150/65 mm Hg, pulse is 100/
min, and respirations are 14/min. Palpation of the neck reveals no thyroid
enlargement or tenderness. Her skin is warm and moist, and a fine hand
tremor is noted. Which of the following is the most likely diagnosis?
A. Graves disease
B. Hashimoto thyroiditis
C. Postpartum thyroiditis
D. Riedel thyroiditis
E. Sheehan syndrome
F. Subacute (de Quervain) thyroiditis
A 65-year-old man develops truncal obesity and a buffalo hump. He is not on

any medications. Early morning cortisol is 35 micrograms/dL (normal 5 to
25 micrograms/dL). Late evening cortisol is 20 micrograms/dL (normal < 10
micrograms/dL). Cortisol production does not suppress with either low or
high dexamethasone. CT scan of the head demonstrates a normal sella
turcica and pituitary gland. An ectopic source of ACTH production is
suspected. A malignancy of which of the following organs is most likely to
be the source of the ACTH?
A. Colon
B. Lung
C. Pancreas
D. Stomach
E. Testis
A 33-year-old woman comes to the physician because of palpitations,

restlessness, sweating, weight loss, and a tremor for the past 3 weeks. She
does not drink coffee, tea, soda, or alcohol, and she does not smoke
cigarettes. Her temperature is 37 C (98.6 F), blood pressure is 130/80 mm
Hg, and pulse is 90/min. Examination shows a fine tremor, lid lag and stare,
and pretibial myxedema. The thyroid gland is diffusely enlarged,
asymmetric, and lobular. A bruit is present over the gland. Laboratory
studies show an undetectable level of thyroid-stimulating hormone, an
increased level of thyroid hormones, and an increased radioactive iodine
uptake (RAIU). The diagnosis of Graves' disease is made and the treatment
options are discussed. The patient selects radioactive iodine therapy. This
patient is at greatest risk for which of the following conditions?
A. Cholestasis
B. Granulocytopenia
C. Hypothyroidism
D. Recurrent laryngeal nerve damage
E. Thyroid carcinoma
A 35-year-old male has been complaining of headaches for the past 6 months
and has been reporting changes in his vision. On examination he has loss of
visual fields bilaterally and gets a magnetic resonance image (MRI) of his
brain. This shows a pituitary adenoma. Which of the following hormones is
most likely to be elevated in this patient?
A. Adrenocorticotropic hormone (ACTH)

B. Growth hormone (GH)
C. Prolactin
D. Somatomedin C
E. Thyroid-stimulating hormone (TSH)
A 61-year-old woman is brought to the hospital by ambulance after being

found unconscious. Her Medic-Alert bracelet states that she has
hypothyroidism. All that is known of her history is that she was found by her
family on her kitchen floor and was nonresponsive and cold to the touch. It is
not clear whether she has been taking her thyroxine therapy. On examination,
her skin is thin, cool, and moist, with nonpitting diffuse edema of her upper
and lower extremities. Her blood pressure is 70/nondetectable mm Hg, pulse
is 40/min, and respirations are 8/min with an oxygen saturation of 82% on
room air. Which of the following is the most appropriate next step in her
management?
A. IV hypertonic saline
B. IV pressor support
C. IV thyroxine
D. Endotracheal intubation and mechanical ventilation
E. Cardiac defibrillation
Explanation
Explanation - Q: 1 Close
The correct answer is C. MRI with gadolinium is considered the most sensitive test for detecting
microadenoma. The test can reveal microadenomas in 20% of normal women.
CT scans can be quite sensitive in the detection of microadenomas, but MRIs are even more so
(choice A).
Insulin-resistance as a result of impaired growth hormone response to insulin-induced

hypoglycemia is not as common (choice B).
The serum prolactin level is elevated due to hypersecretion in 30-50% of patients (choice D).
For the optic chiasm to be compressed in order to cause visual field changes, the microadenoma
would have to be quite large, and a screening test based on this finding would be ineffective
(choice E).
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Explanation
The correct answer is E. Hypokalemia can occur in each of the above conditions. The
combination of alkalosis and hypokalemia suggests surreptitious vomiting. By vomiting, the
patient loses protons in the form of acid in the stomach, effectively making her alkalotic. To
correct for the alkalosis, the proton-potassium antiport system pumps out protons and increases
the intracellular concentration of potassium, thus decreasing the serum potassium level. The
patient is hypotensive from the fluid loss.
Chronic diarrhea (choice A) is characterized by acidosis, rather than alkalosis, since basic salts are
lost through the lower gastrointestinal system. Potassium is still lost, and the patient will be
hypokalemic. Given the fluid loss, she would be hypotensive as well.
Cushing syndrome (choice B) is caused by excessive amounts of cortisol. Clinical features

include hypertension, central obesity, and muscle weakness. Cortisol excess will also cause
hypokalemia and alkalosis, however, the patient would not be hypotensive.
Licorice (choice C), or anise, contains a mineralocorticoid-like substance called glycyrrhetinic

acid. Ingestion may lead to hypokalemia, hypertension, and metabolic alkalosis.
Primary aldosteronism (choice D) can be the result of an adrenal adenoma that produces excessive
amounts of aldosterone. The aldosterone increases the reabsorption of sodium and the excretion of
potassium and hydrogen ions in the distal renal tubules, producing hypokalemia, alkalosis, and
hypertension. The sodium retention leads to increased intravascular volume.
- - -
Explanation
The correct answer is E. Hypertension with an adrenal mass should bring to mind two distinct
conditions: an epinephrine/norepinephrine-secreting pheochromocytoma, or an aldosterone-
secreting adrenocortical tumor (which can produce Conn syndrome). Although both of these can
produce hypertension, other aspects of the clinical presentation are quite different.
Pheochromocytoma can produce either episodic severe hypertension or continuous hypertension.
In either situation, electrolyte studies are usually normal. In contrast, Conn syndrome (which this
patient has) often shows prominent symptoms related to hypokalemia, including weakness,
paresthesias, and transient paralysis. The treatment of hypertension related to high aldosterone
levels is to block the aldosterone activity with the potassium-sparing diuretic (and anti-aldosterone
agent) spironolactone.
Captopril (choice A) is an angiotensin converting enzyme (ACE) inhibitor that works well to
reduce blood pressure in many patients by blocking the renin-angiotensin system; however, it is
less effective when there is already an excess of aldosterone present.
Furosemide (choice B), a loop diuretic, and hydrochlorothiazide (choice C), a thiazide type
diuretic, would tend to make the patient's hypokalemia worse.
Propanolol (choice D) is a beta blocker that would reduce blood pressure but would not
specifically counter the cause of this patient's hypertension.
- - -
Explanation
The correct answer is E. This patient has hyperparathyroidism, which is characterized by an

elevation of circulating parathyroid hormone (PTH), most likely due to a benign adenoma. An
elevation of PTH leads to high calcium and low phosphate levels. These patients often have
unbalanced bone resorption and formation leading to osteopenia and fractures, recurrent
nephrolithiasis, vague abdominal symptoms, weakness, and easy fatigability. "Bones, stones,
abdominal groans, and moans" is a mnemonic used to remember the symptoms. The treatment is
typically surgical.
Decreased excretion of uric acid (choice A) is the most common cause of hyperuricemia and gout.
It can be caused by increased tubular absorption, decreased tubular secretion, or decreased
glomerular filtration. These individuals typically have a uric acid level greater than 7 mg/dL.
Complications include gouty arthritis, nephrolithiasis, renal insufficiency, and renal failure.
The development of thyroid-stimulating hormone receptor antibodies (choice B) is the underlying

mechanism of Graves disease, which is one of the most common causes of hyperthyroidism. The
signs and symptoms include a diffuse, toxic goiter, tachycardia, tremor, nervousness, and
exophthalmos. This patient does not fit this description.
An elevation of circulating aldosterone (choice C) is a sign of Conn disease, which is caused by

adrenal hyperplasia or an adenoma. These patients typically have hypertension and hyperkalemia.
This patient has neither of these findings.
An elevation of circulating cortisol (choice D) is a sign of Cushing syndrome, which may be

caused by a pituitary adenoma (Cushing disease), an adrenal cortical tumor, ectopic ACTH
production (a lung tumor), or glucocorticoid therapy. Signs and symptoms include central obesity,
moon facies, muscle wasting, osteoporosis, striae, bruising, hypertension, menstrual irregularities,
hirsutism, and acne. This patient has osteopenia, but none of the other signs or symptoms.
- - -
Explanation
The correct answer is D. This patient is hypothyroid. Silent lymphocytic thyroiditis is a

surprisingly common disorder of postpartum women, occurring in about 5% to 10% of these
patients. It appears to be an autoimmune reaction to the thyroid gland (possibly somewhat related
to Hashimoto thyroiditis) that can produce transient hyperthyroidism (related to follicle
destruction) followed by hypothyroidism (that may be either permanent or resolve within 1 year).
It is thought that many cases are not diagnosed.
Euthyroid sick syndrome (choice A) is typically seen in intensive care patients who do not have
true clinical hypothyroidism.
Graves disease (choice B) is a cause of hyperthyroidism.
Iodine deficiency (choice C) is now a rare cause of goiter and hypothyroidism in the U.S.
Subacute thyroiditis (choice E) characteristically produces a tender thyroid gland.
- - -
Explanation
The correct answer is C. In the presence of hypertension of recent onset, along with dermal
striae, easy bruisability, and evidence of glucose intolerance (glycosuria), hypercortisolism should
be suspected. The first test to perform is the dexamethasone suppression, which consists of
administering 1 mg of dexamethasone at 11 PM, and then measuring serum cortisol levels in a
blood sample drawn at 8 AM next day. Abnormally high cortisol levels after this test confirms
hypercortisolism. The next step is to find the source of excessive cortisol or ACTH. Other
manifestations of hypercortisolism include osteoporosis, muscle wasting, psychologic alterations,
hirsutism, and granulocytic leukocytosis with lymphopenia.
Baseline plasma ACTH measurement (choice A) should be performed after a diagnosis of

hypercortisolism has been confirmed by dexamethasone suppression test. This test is used to
determine whether excessive cortisol production is secondary to increased ACTH levels.
CT scans of the chest and abdomen (choice B) are performed to look for ectopic sources of
ACTH. These radiologic studies are especially useful in finding neoplasms that may manifest with
inappropriate ACTH secretion, the most frequent of which being small cell carcinoma of the lungs.
Measurement of midnight serum cortisol level (choice D) helps distinguish Cushing syndrome
from other causes of pseudo-Cushing states, such as alcoholism, depression, and anorexia
nervosa. This test requires the patient to remain in the same time zone for 3 consecutive days, be
without food for at least 3 hours, and have an indwelling catheter ready for the blood draw.
Measurement of 24-hour urine cortisol and creatinine (choice E) may become necessary for some
patients in whom the dexamethasone suppression test gives equivocal results. The above
mentioned pseudo-Cushing states, however, may show abnormally high levels of free urine
cortisol.
MRI of the head (choice F) is the method of choice to study the pituitary gland and look for
adenomas. ACTH-producing adenoma is the cause of Cushing disease, which accounts for 70% of
cases of hypercortisolism not due to exogenous corticosteroids.
- - -
Explanation
The correct answer is E. The patient is in diabetic ketoacidosis, as indicated by the acetone scent
to the breath and the glucose and ketones in the urine. Diabetic ketoacidosis produces an increased
anion gap, since the anion for the acid that is produced (acetoacetate) is not one of the usually
measured ions. The anion gap is usually estimated by subtracting the sum of the Cl- and HCO3-
concentrations from the plasma Na+ concentration; the normal value for the anion gap is 12 ± 4
mEq/L. Causes of increased anion gap include conditions that produce ketoacidosis (diabetes
mellitus, alcoholism, starvation), renal failure with retained sulfate and phosphate, drugs or
metabolites (salicylate or ethylene glycol poisoning), alkalosis with increased negative charge of
protein anions, and dehydration (hemoconcentration).
6 mEq/L (choice A) is below the lower limit of normal. The anion gap may be decreased because
of a decrease of negatively charged serum proteins (eg, in hypoalbuminemia), an increase in
proteins carrying few negative charges (eg, hypergammaglobulinemia), or an increase in
unmeasured cations (e.g., magnesium, calcium, or lithium).
The other values (choice B, C, and D) are within normal limits.
- - -
Explanation
The correct answer is C. The patient initially had osteitis fibrosa cystica as a result of the
primary hyperparathyroidism. When the adenoma was removed and PTH level decreased, the
skeleton underwent rapid remineralization. This created an increase in calcium requirement. Once
the repair was complete, the calcium demand decreased.
If the remaining glands were destroyed (choice A) she would have been permanently
hypocalcemic.
In pseudohypoparathyroidism (choice B), there is end organ resistance to PTH, resulting in

kidneys and bones being unresponsive. Patients have hypocalcemia and hyperphosphatemia.
Severe pancreatitis would cause saponification and hypocalcemia (choice D). She would also
have symptoms of epigastric pain.
If the wrong gland were removed, she would be still hypercalcemic (choice E).
- - -
Explanation
The correct answer is D. Sheehan syndrome is a rare cause of panhypopituitarism, caused by

necrosis of the pituitary gland occurring during deliveries complicated by severe hypotension.
Signs and symptoms of panhypopituitarism may become apparent many months or even years
after parturition. The diagnosis is established by measuring plasma levels of growth hormone and
cortisol after an insulin challenge, as well as by evaluating thyroid hormones and TSH levels. It is
treated with administration of hydrocortisone and thyroid hormones.
Postpartum depression (choice A) develops within 6 months postpartum. Usually, symptoms of

depression are mild. In 10% of these cases, however, depression may be so severe as to require
hospitalization and intensive antidepressant treatment. Although depression may mimic symptoms
of several endocrine illnesses and vice versa, the signs detected on physical examination, along
with the long interval following delivery in this case, are more consistent with hypopituitarism.
Primary adrenal insufficiency (choice B) would explain only part of the syndrome in this case,
such as fatigue and hypotension, but not amenorrhea, cold intolerance, and skin changes. In
addition, primary hypocortisolism (i.e., due to destruction of adrenal glands) would be associated
with skin hyperpigmentation.
Primary hypothyroidism (choice C) may produce a similar clinical picture, but the history of
difficult parturition with abundant blood loss and the wide-ranging symptomatology suggesting
multiple endocrine deficits make panhypopituitarism more likely.
- - -
Explanation
The correct answer is A. While there is some variation in the usage of the term, Addison disease
is usually taken to mean adrenocortical insufficiency related to disease that destroys the adrenal
gland. Most authors separate out secondary adrenocortical insufficiency due to pituitary failure
and recent or current exogenous steroid therapy. True Addison disease, which is not related to
inadequate pituitary secretion of ACTH, frequently has stigmata of hyperpigmentation relating to
a melanocyte-stimulating hormone (MSH) effect seen with high ACTH levels. The biochemical
basis of this is a homology between part of the ACTH molecule and the MSH molecule. Typical
hyperpigmentation features include black freckles of the shoulders, head, and neck; bluish-black
discoloration of areolas and mucous membranes (both oral and anogenital); and diffuse tanning,
specifically including non-sun-exposed skin. The pattern of laboratory screening studies
illustrated in the question stem is also very suggestive, with very low serum sodium, high
potassium, low bicarbonate, and high serum urea nitrogen.
A large, furrowed tongue (choice B) suggests acromegaly.
Many spider angiomas (choice C) suggest chronic liver disease.
Protruding eyeballs (choice D) suggest Grave's disease.
Small glistening bumps on the lips (choice E) suggests the mucosal neuromas of MEN IIb.
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Explanation
The correct answer is A. This patient has central diabetes insipidus. People can slowly develop
dietary or drinking habits that seem perfectly normal to them, but appear strikingly unusual to
other people. This frequently happens with conditions related to fluid balance, and the patient may
be coping with a significant underlying problem without even realizing it. It may only be when
something unusual happens, such as this woman's car trip, that the patient comes to medical
attention. In this case, the patient essentially underwent a water deprivation test, but without the
close medical supervision always offered when such a test is performed in a hospital setting. The
facts that she continued to produce dilute urine and that the urine osmolarity could be increased
with vasopressin indicate that the diabetes insipidus probably has a central origin. A head CT
would likely confirm the diagnosis by showing a large pituitary adenoma, which could
compromise antidiuretic hormone flow down the pituitary stalk.
Compulsive water drinking (choice B) is more likely to mimic nephrogenic diabetes insipidus
than central diabetes insipidus.
Diabetes mellitus (choices C and D) can produce high urine flow rates, but only secondary to an
osmotic diuresis seen when urine glucose is high.
Nephrogenic diabetes insipidus (choice E) does not respond to vasopressin.
- - -
Explanation
The correct answer is A. This patient most likely has Addison's disease, which is primary
adrenocortical deficiency. It is a rare disease that is caused by a progressive destruction of the
adrenal glands, usually due to idiopathic atrophy, surgery, infection, or hemorrhage. The clinical
symptoms include weakness, weight loss, hyperpigmentation, nausea and vomiting, and
hypotension. Laboratory findings include hyponatremia (due to aldosterone deficiency),
hyperkalemia, and normocytic anemia with eosinophilia and lymphocytosis. The diagnosis is
made with the ACTH stimulation test. Cortisol and aldosterone levels do not increase when the
ACTH is given. The treatment is glucocorticoid and mineralocorticoid replacement.
Conn's syndrome (choice B) is primary aldosteronism due to an aldosterone-producing adenoma.

Symptoms include headaches and hypertension. Laboratory findings include hypokalemia and
hypernatremia. Metabolic alkalosis is common.
Cushing's disease (choice C) is caused by an ACTH-producing pituitary tumor that produces

excess aldosterone and adrenal androgen secretion. The symptoms include weakness and fatigue,
increased weight, osteoporosis, hypertension, striae, amenorrhea, edema, and impaired glucose
tolerance. A high-dose dexamethasone suppression test, CT scans and MRIs are used to make the
diagnosis. Treatment is surgery.
Cushing's syndrome (choice D) is similar to Cushing's disease except that it is due to adrenal
hyperplasia, an adrenal neoplasm or exogenous, iatrogenic causes.
Syndrome of inappropriate antidiuretic hormone secretion (choice E) is characterized by

hyponatremia, anorexia, nausea and concentrated urine. It is caused by head trauma, a tumor or
infections. The treatment is fluid restriction.
- - -
Explanation
The correct answer is A. This patient is seriously ill, with low T4 and low T3, but normal TSH.
This is typical for euthyroid sick syndrome, which occurs in many seriously ill patients who do
not have clinical hypothyroidism. It can be enough of a diagnostic problem that some references
suggest that thyroid hormones not be measured in patients in the intensive care unit unless they
are strongly clinically suspected of having thyroid disease. The TSH level is usually most helpful
in distinguishing euthyroid sick syndrome from true hypothyroidism, as it often above 30 mU/mL
in true hypothyroidism and may be below normal, normal, or minimally elevated in euthyroid sick
syndrome. Disproportionately decreased T3 is also typical of euthyroid sick syndrome, and T4
may be normal or decreased.
Graves disease (choice B) produces hyperthyroidism.
Hashimoto disease (choice C) typically produces a rubbery goiter.
Medullary carcinoma of the thyroid (choice D) is rare and would probably not affect the serum
thyroid hormone levels unless it was very extensive.
Silent lymphocytic thyroiditis (choice E) can cause hypothyroidism that typically occurs in the
postpartum period.
- - -
Explanation
The correct answer is D. Early intervention can prevent osteoporosis. Later intervention can halt
its progression, but it is not currently possible to reverse established disease. All current therapies
for osteoporosis are directed at inhibiting bone resorption. Bone loss is greatest within the first
year of menopause so these agents are likely to be most efficacious if started at this time. Estrogen
reduces the rate of bone loss and improves density. The beneficial effects of estrogen replacement
are well-documented, and it is estimated that less than 20% of women are taking estrogens,
despite their enormous benefit. Additionally, estrogen replacement has been shown to be
important for prevention of coronary disease in this age group.
Bisphosphonates (choice A) are agents that inhibit osteoclastic bone resorption. These agents are
efficacious for both prevention and treatment of disease. In some trials, their effect on augmenting
bone density is similar to that of estrogens. However, given the side effects of these agents
(esophagitis) as well as the other beneficial effects of estrogens (effects on HDL, LDL and
coronary disease), estrogen is still the agent of choice for prevention.
Calcitonin (choice B) is FDA-approved only for established disease, but studies have shown
conflicting results regarding its efficacy.
Calcium and vitamin D (choice C) are critical components of prevention and ongoing treatment,
but the effects of giving calcium and vitamin D supplements are proportional to the duration of
therapy. Most postmenopausal women receive less than the recommended calcium intake (1500
mg/day) and have hypovitaminosis D (<15 ng/mL 25-hydroxy vitamin D levels). Calcium and
vitamin D is the cornerstone of good therapy whether hormone replacement is utilized or not, but
the effects are generally not significant unless begun early in life.
Sodium fluoride (choice E) has been supplanted by newer therapies and is used primarily in
Europe for treatment of established disease.
- - -
Explanation
The correct answer is D. Tangier disease is a rare familial disorder characterized by alpha-
lipoprotein deficiency, which leads to very low high-density lipoprotein (HDL), recurrent
polyneuropathy, lymphadenopathy, and hepatosplenomegaly due to storage of cholesterol esters
in reticuloendothelial cells. Although you may never see this disease, the association of orange-
yellow tonsillar hyperplasia (due to the cholesterol ester deposition there as well) with Tangier
disease is a sufficiently distinctive clue in physical diagnosis to be worth remembering. (One rule
of thumb in medicine is that although you will probably never see most of the very rare diseases,
you will almost certainly see some of them.)
The presence of multiple angiokeratomas (choice A) on the lower half of the body suggests Fabry
disease.
Grey-brown pigmentation of the forehead, hands, and pre-tibial region (choice B) suggests
Gaucher disease.
Irregular black deposits of clumped pigment in the peripheral retina (choice C) are characteristic
of retinitis pigmentosa, which may occur in association with abetalipoproteinemia and Refsum
disease.
Pingueculae (choice E) could suggest Gaucher disease, but this could also occur in normal adults.
- - -
Explanation
The correct answer is D. Hypercalcemia can be treated with IV saline and furosemide. Fluid
replacement with IV saline and forced diuresis with saline and a loop diuretic, such as furosemide,
is a rapid and safe way to lower serum calcium and should be the initial approach to therapy. This
patient has lung cancer and is probably exhibiting a paraneoplastic secretion of parathyroid-related
hormone, which is making him hypercalcemic.
Calcitonin (choice A), a hormone secreted by the parafollicular cells of the thyroid, inhibits
osteoclast activity and decreases the rate of bone loss and fractures in osteoporosis. It may be
added after IV hydration and diuresis with furosemide.
Etidronate (choice B) is a bisphosphonate that prevents bone resorption by inhibiting osteolytic

activity. It is often used in preventive therapy for osteoporosis. However, it would be of limited
value in this acute setting.
Hydrochlorothiazide (choice C) is a thiazide diuretic that decreases urinary calcium excretion and
can cause hypercalcemia.
Prednisone (choice E) is a glucocorticoid that is effective in treating hypercalcemia caused by

vitamin D excess, sarcoidosis, and some hematologic malignancies. However, it does not lower
calcium in most cases of hypercalcemia associated with solid tumors.
- - -
Explanation
The correct answer is C. The clinical manifestations are consistent with hyperthyroidism.
Especially suggestive are heat intolerance and systolic hypertension with a low diastolic pressure.
Anxiety, hand tremor, and warm skin are additional characteristic symptoms. Postpartum
thyroiditis is a frequent, but usually self-limited, postpartum complication. It develops a few
weeks following delivery and appears to result from an autoimmune response. A minority of cases
are followed by hypothyroidism. The gland is not swollen or finely nodular as occurs in
Hashimoto thyroiditis (choice B), which is also due to autoantibodies against thyroid antigens.
Graves disease (choice A) refers to thyrotoxicosis developing as a result of an autoimmune

mechanism involving stimulatory autoantibodies directed against TSH receptors. The thyroid is
usually enlarged and warm. Ophthalmopathy (exophthalmos) is usually present.
Riedel thyroiditis (choice D), also known as chronic fibrous thyroiditis, is an uncommon form of
chronic thyroiditis leading to sclerosis of the thyroid gland and adjacent structures. It manifests in
middle-aged or elderly women with slowly developing hypothyroidism and is characterized by a
stony hard thyroid on palpation.
Sheehan syndrome (choice E) is a rare syndrome due to complete ischemic necrosis of the
anterior pituitary gland, secondary to hypotension during complicated deliveries. It manifests with
panhypopituitarism (including secondary hypothyroidism).
Subacute (de Quervain) thyroiditis (choice F) is a relatively common disorder characterized by

painful swelling of the thyroid and often associated with dysphagia. It may persist for months but
usually subsides spontaneously.
- - -
Explanation
The correct answer is B. Cushing syndrome is a cluster of clinical abnormalities seen in the
setting of chronic exposure to high cortisol levels. Truncal obesity, buffalo hump, increased
susceptibility to infection, hypertension, and glucose intolerance are common manifestations.
Cushing syndrome can be due to administration of exogenous corticosteroids, adrenal hyperplasia
or tumor, pituitary adenoma, or ectopic ACTH production by another malignancy. The later is
most commonly a small cell carcinoma of the lung. Lung cancers are also notorious for a wide
variety of other paraneoplastic syndromes, including hypercalcemia, hypophosphatemia,
somatostatinoma syndrome (with prominent GI complaints), syndrome of inappropriate
antidiuretic hormone secretion (SIADH), Eaton-Lambert syndrome, polymyositis, cerebellar
degeneration, peripheral neuropathy, osteoarthropathy, marantic endocarditis, migratory
thrombophlebitis, and disseminated intravascular coagulation.
Cancers of the colon (choice A) can cause GI symptoms and anemia related to blood loss, but are
not a prominent cause of endocrine-related paraneoplastic syndromes.
Islet cell cancers of the pancreas (choice C) can secrete clinically significant amounts of insulin,
gastrin, glucagon, and vasoactive intestinal peptide, but do not usually secrete ACTH or
corticosteroids.
Cancers of the stomach (choice D) can cause symptoms such as jaundice and ascites related to
direct extension into perigastric sites, but are not a source of endocrine-related paraneoplastic
syndromes.
While some testicular cancers (choice E) can secrete tiny amounts of hormones such as human
chorionic gonadotropin (hCG), clinically significant endocrine disease does not usually occur.
- - -
Explanation
The correct answer is C. Hypothyroidism is the main complication of radioactive iodine therapy,
affecting up to 70% of patients in 10 years. Radioactive iodine therapy is a safe and effective
treatment for Graves' disease because it can provide the same ablative effects of surgery without
the surgical complications. There is no evidence that this treatment increases the risk for
carcinoma (choice E).
Cholestasis (choice A) and granulocytopenia (choice B) are side effects of long-term antithyroid
therapy (propylthiouracil).
Recurrent laryngeal nerve damage (choice D) is a complication of subtotal thyroidectomy.

Subtotal thyroidectomies provide rapid control of the disease but can lead to nerve damage,
hemorrhage, hypothyroidism, and hypoparathyroidism.
- - -
Explanation
The correct answer is C. 50% of pituitary adenomas have been found to secrete prolactin. Levels
of this hormone must be measured in a patient suspected of having a pituitary tumor.
Cushing's disease due to an excess of adrenocorticotropic hormone (choice A) is considerably less

common.
Acromegaly due to growth hormone excess is an infrequent complication as well (choice B).
Somatomedin C, which is insulin-like growth factor I, is increased in acromegaly but not in

patients with pituitary tumors (choice D).
Overproduction of thyroid stimulating hormone in these situations is rare (choice E).
- - -
Explanation
The correct answer is D. Although this patient is likely in myxedema coma, the basics of
medical management ALWAYS take precedence. Airway, breathing, and circulation evaluation
are a priority in this patient with a respiratory rate less than 10 and clearly abnormal oxygen
saturation of her blood. In this patient, securing an airway and then addressing her remaining
issues are of paramount importance.
IV hypertonic saline (choice A) would be incorrect, for two reasons. First, the ABCs of medical
management take priority. Second, although many severely hypothyroid patients are
hyponatremic, this has yet to be demonstrated in this patient.
In this setting, pressors (choice B) need to be given via central venous line, and this access has not
yet been established in this patient.
IV thyroxine (choice C) would be the appropriate treatment AFTER thyroid function tests were
verified and the patient was stabilized.
Cardiac defibrillation (choice E) is incorrect because it is not yet known whether this person is
experiencing a dysrhythmia that would respond to this intervention. The two most common types
of such rhythms seen in this type of emergency setting are ventricular fibrillation and ventricular
tachycardia.
- - -

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file:///C|/Documents%20and%20Settings/Home/Desktop/Downloads/bo...tep2%20q%20bank%20new!!!%20PART03/Medicine%202/endo%2021/1.

A 45-year-old woman presents to clinic with a 4-month history of headaches

A. Computerized tomography (CT) scan

A 55-year-old man consults a physician because of episodic weakness and

A 64-year-old woman comes to the emergency department because of severe

Chloride ...........94 mEq/L

Calcium ..........13 mEq/L

Uric acid.........5 mg/dL

A splint is placed on her wrist and a follow-up visit is scheduled. Which of

A. Decreased excretion of uric acid

A. Euthyroid sick syndrome

A 48-year-old man comes to the physician because of the recent onset of

A. Baseline plasma ACTH measurement

A 23-year-old type 1 diabetic is brought to the emergency department after

A 60-year-old woman complains of a 1-year history of bone pains, anorexia,

A. Her remaining 3 parathyroid glands were destroyed

One year following a difficult birth, which was accompanied by considerable

A 45-year-old man presents to a physician with complaints of weakness,

A. Black freckles on the shoulders

A 45-year-old woman is taken to an emergency department after an all day

A. Central diabetes insipidus

A 53-year-old man comes to the physician because of progressive weakness

Chloride ......................95 mEq/L

Band forms ......................4%

Which of the following is the most likely diagnosis?

A 45-year-old alcoholic man with cirrhosis is transferred to the intensive care

A. Euthyroid sick syndrome

A 52-year-old woman is seen by in clinic for advice on osteoporosis. She has

A 18-year-old man presents for a health maintenance examination. He has a

A 42-year-old man presents with a 1-day history of increasing nausea,

A 25-year-old woman comes to the physician 4 weeks after an uneventful

A 65-year-old man develops truncal obesity and a buffalo hump. He is not on

A 33-year-old woman comes to the physician because of palpitations,

A. Adrenocorticotropic hormone (ACTH)

A 61-year-old woman is brought to the hospital by ambulance after being

Insulin-resistance as a result of impaired growth hormone response to insulin-induced

Cushing syndrome (choice B) is caused by excessive amounts of cortisol. Clinical features

Licorice (choice C), or anise, contains a mineralocorticoid-like substance called glycyrrhetinic

The correct answer is E. This patient has hyperparathyroidism, which is characterized by an

The development of thyroid-stimulating hormone receptor antibodies (choice B) is the underlying

An elevation of circulating aldosterone (choice C) is a sign of Conn disease, which is caused by

An elevation of circulating cortisol (choice D) is a sign of Cushing syndrome, which may be

The correct answer is D. This patient is hypothyroid. Silent lymphocytic thyroiditis is a

Graves disease (choice B) is a cause of hyperthyroidism.

Subacute thyroiditis (choice E) characteristically produces a tender thyroid gland.

Baseline plasma ACTH measurement (choice A) should be performed after a diagnosis of

The other values (choice B, C, and D) are within normal limits.

In pseudohypoparathyroidism (choice B), there is end organ resistance to PTH, resulting in

The correct answer is D. Sheehan syndrome is a rare cause of panhypopituitarism, caused by

Postpartum depression (choice A) develops within 6 months postpartum. Usually, symptoms of

A large, furrowed tongue (choice B) suggests acromegaly.

Many spider angiomas (choice C) suggest chronic liver disease.

Protruding eyeballs (choice D) suggest Grave's disease.

Nephrogenic diabetes insipidus (choice E) does not respond to vasopressin.

Conn's syndrome (choice B) is primary aldosteronism due to an aldosterone-producing adenoma.

Cushing's disease (choice C) is caused by an ACTH-producing pituitary tumor that produces

Syndrome of inappropriate antidiuretic hormone secretion (choice E) is characterized by

Graves disease (choice B) produces hyperthyroidism.

Hashimoto disease (choice C) typically produces a rubbery goiter.

Etidronate (choice B) is a bisphosphonate that prevents bone resorption by inhibiting osteolytic

Prednisone (choice E) is a glucocorticoid that is effective in treating hypercalcemia caused by

Graves disease (choice A) refers to thyrotoxicosis developing as a result of an autoimmune